Tapering Benzodiazepines: What We Don’t Know

The hyperbolic taper is popular for benzodiazepine withdrawal, but it is based entirely on pharmacological theory and expert consensus, not clinical trials

Ninety percent of the benzodiazepine tapering guideline rest on expert opinion, not evidence

STUDY: Kleykamp BA et al, J Addict Med 2026;

STUDY TYPE: Systematic review with research recommendations

FUNDING: US Food and Drug Administration (FDA)

Background

Benzodiazepines are recommended short-term, but tapering is difficult, and this review of 57 studies reveals how little we know.

Results

Of 29 guideline recommendations, 26 (90%) were based on expert consensus, not direct data. Most evidence is low quality.

No adjunctive medication stood out. Melatonin, lithium, pregabalin, paroxetine, buspirone, carbamazepine, and others each failed to increase the likelihood of successful taper in controlled studies. While they don’t change the bottom line, some improved limited symptoms, like sleep with pregabalin or melatonin; or anxiety with carbamazepine.

Cognitive behavioral therapy showed modest benefits over usual care in a few studies, but those gains faded within three months.

The studies that did exist were riddled with problems. Tapers moved faster than clinical practice recommends: many cut doses by 25–50% every one to two weeks. No studies evaluated hyperbolic “microtapering” approaches.

Switching patients from short-acting to long-acting benzodiazepines like diazepam for tapering is common practice, but no controlled data support it. Most participants were women over 50, with benzodiazepine use histories ranging from 2 to more than 20 years. However, older age adults were underrepresented.

Risks of Tapering

One study found an increase in mortality with tapering (though not randomized), and a survey of 1,200 patients found that 54% reported suicidal ideation during tapering.

Practice Implications

1. Careful, personalized care is the call when evidence is lacking. Expert opinions can guide us, but it’s not rigid guidance.
2. Despite its limitations, CBT does have the best evidence for benzo WD. Here’s the workbook.
3. I start with this brief guide, and follow the symptoms closely with the rating scale attached to it.